LOGBOOK PERTEMUAN 02

PROSES KEPERAWATAN JIWA

Pertemuan 01
MK Keperawatan Jiwa
Penugasan
2.1. Menjelaskan Proses Keperawatan Kesehatan Jiwa
2.2. Mengisi Format Pengkajian Keperawatan Kesehatan Jiwa
2.3. Menuliskan contoh implementasi dan evaluasi

Kelas Reguler
 LOGBOOK PERTEMUAN 02
Penugasan 2.1: Proses Keperawatan Kesehatan Jiwa
Tujuan :
Setelah menyelesaikan Pertemuan ini, peserta didik diharapkan mampu :
1. Memahami Proses Keperawatan Kesehatan Jiwa
2. Memahami langkah-langkah proses keperawatan kesehatan jiwa

Aktifitas 2.1
Untuk memahami Proses Keperawatan Kesehatan Jiwa

Tujuan : aktifitas ini membantu peserta didik memahami Proses Keperawatan Kesehatan Jiwa

Soal 1. Tuliskan Langkah-langkah Proses Keperawatan Kesehatan Jiwa

LOGBOOK PERTEMUAN 02
 Penugasan 2.2: Pengkajian
Tujuan :
Setelah menyelesaikan Pertemuan ini, peserta didik diharapkan mampu :
1. Memahami Proses Keperawatan Kesehatan Jiwa
2. Mengisi Format Pengkajian Keperawatan Kesehatan Jiwa

Aktifitas 2.2
Untuk memahami Proses Keperawatan Kesehatan Jiwa

Tujuan : aktifitas ini membantu peserta didik memahami Proses Keperawatan Kesehatan Jiwa

Soal 1. Baca dan diskusikan dengan teman sekelompok tentang format pengkajian keperawatan
kesehatan jiwa. Identifikasi satu kasus fiktif dan Isi data sesuai dengan aspek yang dikaji. (bahas
dalam kelompok dan dokumentasikan secara individu.

FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

Ruang rawat :

I. IDENTITAS KLIEN

Inisial : ...................................

Jenis kelamin : ...................................

Umur : ...................................

Informan : ....................................

Tanggal masuk RS : ...................................

Tanggal pengkajian : ...................................

Nomor register : ...................................

II. ALASAN MASUK

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

……

III. FAKTOR PREDISPOSISI

1. Pernah mengalami gangguan jiwa dimasa lalu : ( ) ya , tahun………….. ( )

tidak

2. Pengobatan sebelumnya : ( ) berhasil ( ) kurang berhasil ( ) tidak

berhasil

3. Masalah Penganiayaan :

Pelaku / usia Korban / usia Saksi / usia

Aniaya fisik
Aniaya seksual
Penolakan
Kekerasan dalam keluarga
Tindakan kriminal

Jelaskan No. 1,2,3 :

…………………………………………………………………………….................................

………………………………………………………………………………………………………………………

………………

Masalah Keperawatan : ………………………………………………………..........................................

……………………………………………………………………………………………………………............

4. Adakah anggota keluarga yang mengalami gangguan jiwa ? ( ) ya ( ) tidak

Hubungan keluarga :

……………………………………………………………………………….................................

Gejala :

………………………………………………………………………………...............................................

…………………………………………………………………………………………………………………….…..

Riwayat pengobatan/perawatan : ………………………………………………………………………

………………………………………………………………………………………………………….

……………...
 5. Pengalaman masa lalu yang tidak menyenangkan ? ( perceraian / perpisahan / konflik dsb )

…………………………………………………………………………………………………………………….

……………………………………………………………………………………………………............................

........................................

PEMERIKSAAN FISIK

1. Tanda-tanda Vital TD : ……mmhg N : …… x/mt S : …… 0C P : …. X/mt

2. Ukur TB : …… Cm BB : …. Kg ( ) turun ( ) naik

3. Keluhan Fisik ( ) ya ( ) tidak

Jelaskan :

…………………………………………………………………………………………...........................

………………………………………………………………………………………………………........................

Masalah keperawatan :

………….....................................................................................................................................

....................................................................................................................................................................

IV. PSIKOSOSIAL

1. Genogram
Jelaskan :

…………………………………………………………………………………………………………................

…………………………………………….......................................................................................................

.....................

Masalah keperawatan :

………….....................................................................................................................................

....................................................................................................................................................................

2. Konsep Diri

a.Gambaran diri :

………………………………………………………………………………...............................................

…………………………………………….......................................................................................................

.....................…………………………...........................................................................................................

b. Identitas diri :

………………………………………………………………………………................................................

…………………………………………….......................................................................................................

.....................……………………………........................................................................................................

c. Peran : ………………………………………………………………………………

................................................

…………………………………………….......................................................................................................

.....................

d. Ideal Diri :

………………………………………………………………………………................................................

…………………………………………...........................................................................................................

.................
e. Harga diri :

……………………………………………………………………………...................................................

…………………………………………….......................................................................................................

.....................

Masalah Keperawatan : ……………………………………………………………………………

3. Hubungan Sosial

a. Orang yang berarti :

……………………………………………………………..........................................................

…………………………………………….......................................................................................................

b. Peran serta kegiatan kelompok/masyarakat: .......................................................................................

…………………………………………….......................................................................................................

..........................

c. Hambatan dalam berhubungan dengan orang lain: .............................................................................

...................................................................................................................................................................

Masalah Keperawatan : …………………………………………………………………………….................

4. Spiritual

a. Nilai dan keyakinan : ……………………………………………............................................

………………………………………...............................................................................................................

.................

b. Kegiatan Ibadah :

………………………………………......................................................................................

…………………………………………….......................................................................................................

.....................
 Masalah Keperawatan : ………….

……………………………………………………………………………....................

V. STATUS MENTAL

1. Penampilan: ( ) tidak rapi ( ) penggunaan pakaian tidak sesuai

( ) cara berpakaian tidak seperti biasanya

Jelaskan : ……………………………………………………………………………………..

………………................……

………………………………………………………………………………………………………........................

..............…

Masalah Keperawatan :

…………………………………………………………………………………………..............

………………………………………………………………………………………………………………………...

...................

2. Pembicaraan: ( ) cepat ( ) keras ( ) gagap ( ) inkoheren ( ) apatis

( ) lambat ( ) membisu ( ) tidak mampu memulai bicara

Jelaskan: ………………………………………………………………………………….

………………………....................

………………………………………………………………………………………………………….....................

................

Masalah Keperawatan ………………………………………………………………………………………….

………………

…………………………………………………………………………………………………...............................

.................
3. Aktivitas Motorik: ( ) Lesu ( ) Tegang ( ) Gelisah ( ) Agitasi ( ) Tik

( ) Grimasen ( ) Tremor ( ) Kompulsif

Jelaskan : ………………………………………………………………………............................................

Masalah Keperawatan : ………………………………………………………………………………..………..

4. Alam Perasaan: ( ) Sedih ( ) Ketakutan ( ) Putus asa ( ) Khawatir

( ) Gembira berlebihan

Jelaskan : ……………………………………………….............................................................................

Masalah Keperawatan : …………………………………………………………………………………………

5. Afek: ( ) Datar ( ) Tumpul ( ) Labil ( ) Tidak sesuai

Jelaskan : ………………………………..................................................……………...............................

Masalah Keperawatan: ……………………………………………………………………………………......

6. Interaksi selama wawancara: ( ) Bermusuhan ( ) Tidak Kooperatif ( ) Mudah tersinggung

( ) Kontak mata kurang ( ) Defensif ( ) Curiga

Jelaskan : ………………………………...............................................……………………………….........

................................................................................................................................................................

Masalah Keperawatan : ………………………………………………………………………........................

……………………………………………………………………………………………................................

7. Persepsi / halusinasi: ( ) Pendengaran ( ) Penglihatan ( ) Perabaan

( ) Pengecapan ( ) Penghidu

Jelaskan :..……………………………………………………...................................................……………

Masalah Keperawatan : …………………………………………………………………..................................

8. Proses Pikir: ( ) Sircumstansial ( ) Tangensial ( ) Kehilangan asosiasi

( ) Flight of idea ( ) Blocking ( ) Pengulangan pembicaraan persevarasi

Jelaskan : ……………………………………………......................................................................................
Masalah Keperawatan : ………………………………………………………………………………………..

………

9. Isi Pikir: ( ) Obsesi ( ) Fobia ( ) Hipokondria ( ) Dipersonalisasi ( ) Ide yang

terkait ( ) Pikiran magis

Waham: ( ) Agama ( ) Somatik ( ) Kebesaran ( ) Curiga ( ) Nihilistik

( ) Sisip pikir ( ) Siap pikir ( ) Kontrol pikir

Jelaskan : ……………………………………………………………………….............................................

Masalah Keperawatan : ……………………………………………………………………………………..…

10. Tingkat kesadaran: ( ) Bingung ( ) Fobia ( ) Hipokondria

Disorientasi: ( ) Waktu ( ) Tempat ( ) Orang

Jelaskan : ………………………………………………………………………..................................................

....................................................................................................................................................................

Masalah Keperawatan : ………………………………………………………………………………................

11. Memori: ( ) Gangguan daya ingat jangka panjang ( ) Gangguan daya ingat jangka pendek

( ) Gangguan daya ingat saat ini ( ) Konfabulasi

Jelaskan : ………………………………………………………………………...............................................…

……………………………………………......................................................................................................

Masalah Keperawatan : ………………………………………………………………………………………….

..

12. Tingkat Konsentrasi dan berhitung: ( ) Mudah Beralih ( ) Tidak mampu berkosentrasi

( ) Tidak mampu berhitung sederhana

Jelaskan : ……………………………………………………………………….......................................

…………………………………………….......................................................................................................

Masalah Keperawatan : ……………………………………………………………………………………...........

13. Kemampuan Penilaian: ( ) Gangguan ringan ( ) Gangguan Bermakna

Jelaskan : ……………………………………………...................................................................................

Masalah Keperawatan : …………………………………………………………………................................

14. Daya Titik diri: ( ) Mengingkari penyakit yang diderita ( ) Menyalahkan hal-hal yang luar

dirinya

Jelaskan : …………………………………………………………….………...................................................

…………………………………………….......................................................................................................

Masalah Keperawatan : ……………………………………………………………………………………………

VII. PERSIAPAN PULANG

1. Makan dan Minum ( ) Bantuan Minimal ( ) Bantuan Total

Jelaskan: ……………………………………………………………………………............................................

Masalah Keperawatan ……………………………………………………………………………………………

2. BAB / BAK: ( ) Bantuan Minimal ( ) Bantuan Total

Jelaskan : ................................................................................................................................................

................................................................................................................................................................

Masalah Keperawatan : …………………………………………………………………………………………

3. Mandi: ( ) Bantuan Minimal ( ) Bantuan Total

Jelaskan : ...........……............................................................................................................................

...............................................................................................................................................................

Masalah Keperawatan : ……………………………………………………………………………………….

4. Berpakaian / Berhias: ( ) Bantuan Minimal ( ) Bantuan Total

Jelaskan : ………………………………………………………………………..............................................

…………………………………………...........................................................................................................

Masalah Keperawatan : ……………………………………………………………………………….................

5. Istirahat / tidur: ( ) Tidur siang, lama : ........................s /d ......................... (....... jam)

( ) Tidur malam, lama : . .......................s /d ....................... (....... jam)

( ) Kegiatan sebelum/sesudah tidur : ………….............................…………………..................................

Jelaskan : ………………………………………………………………………............................................

.....

………………………………………………………………………………….................................................M

asalah Keperawatan : ………………………………………………………………………………………….

6. Penggunaan obat: ( ) Bantuan minimal ( ) Bantuan Total

Jelaskan : ………………………………………………………………………................................................

...........................……………………………………………............................................................................

Masalah Keperawatan : …………………………………………………………………………………………...

7. Pemeliharaan Kesehatan: Perawatan lanjut : ( ) ya ( ) tidak

Perawatan pendukung : ( ) ya ( ) tidak

8. Kegiatan di dalam rumah: Mempersiapkan makan : ( ) ya ( ) tidak

Menjaga kerapihan rumah : ( ) ya ( ) tidak
Mencuci pakaian : ( ) ya ( ) tidak
Mengatur keuangan : ( ) ya ( ) tidak

Jelaskan : ..............................……………………………………………........................................................

...................................................................................................................................................................

…………………………………………….......................................................................................................

...................................................................................................................................................................

Masalah Keperawatan : …………………………………………………………...............................................

9. Kegiatan Diluar rumah: Belanja : ( ) ya ( ) tidak

Transportasi : ( ) ya ( ) tidak
Lain-lain : ( ) ya ( ) tidak

Jelaskan: …………………………………………….....................................................................................
....................................................................................................................................................................

Masalah Keperawatan : ……………………………………………………………………………………..........

VIII. MEKANISME KOPING

Adaptif Mal adaptif
( ) Bicara dengan orang lain ( ) Minum alkohol
( ) Mampu menyelesaikan masalah ( ) reaksi lambat/berlebihan
( ) Tehnik relaksasi ( ) Bekerja berlebihan
( ) Aktivitas konstruktif ( ) Menghindar
( ) Mncederai diri/orang lain/barang
( ) Lain-lain

Jelaskan ……………………………………………........................................................................................

...................................................................................................................................................................

....................................................................................................................................................................

...................................................................................................................................................................

Masalah Keperawatan : ……………………………………………………………………………………..........

IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Klien berhubungan dengan dukungan kelompok spesifik ………………………………………..…………

…………………………………………….......................................................................................................

Masalah berhungan dengan lingkungan fisik ……………………..........................................……………

……………………………………………...................................................................................................

Masalah berhungan dengan pendidikan spesifik …………........................................……………………

…………………………………………….......................................................................................................

Masalah berhubungan dengan pekerjaan spesifik ………………........................................……………

…………………………………………….......................................................................................................

Masalah berhubungan dengan perumahan spesifik …………………........................................………..

…………………………………………….......................................................................................................

Masalah berhubungan dengan ekonomi spesifik …………………..........................................………….

……………………………………………......................................................................................................

Masalah berhubungan dengan pelayanan kesehatan ………….....................................……………….

Jelaskan : ………………………………………………………………………………………..………………

…………………………………………….......................................................................................................

................................................................................................................................................................

Masalah keperawatan : ………………………………………………………………………………………....

X. KURANG PENGETAHUAN TENTANG

( ) Penyakit jiwa ( ) Sistem pendukung
( ) Faktor predisposisi ( ) Kondisi fisik
( ) Mekanisme koping ( ) obat-obatan
( ) Lain-lain

Jelaskan : …………………………………………………………………………………………..…………….

…………………………………………….......................................................................................................

Masalah keperawatan : …………………………………………………………………………………………

ASPEK MEDIS

Diagnosa medik : …………………………………………………………………………………………

Terapi medik : ……………………………………………………………..……………………………

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XI. ANALISA DATA

NO DATA MASALAH

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XII. POHON MASALAH

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 ………………………………………….

XIII. DAFTAR DIAGNOSA KEPERAWATAN

a. ………………………………………………………………....................................................

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b. ………………………………………………………………....................................................

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c. ………………………………………………………………....................................................

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d. ………………………………………………………………....................................................

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e. ………………………………………………………………....................................................

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f. ………………………………………………………………....................................................

g. Dst

LOGBOOK PERTEMUAN 02
Penugasan 2.3: Dokumentasi Catatan Perkembangan (Implementasi dan
Evaluasi)
Tujuan :
Setelah menyelesaikan Pertemuan ini, peserta didik diharapkan mampu :
1. Memahami Proses Keperawatan Kesehatan Jiwa
2. Menuliskan contoh implementasi dan evaluasi

Aktifitas 2.3
Untuk memahami Proses Keperawatan Kesehatan Jiwa
 Tujuan : aktifitas ini membantu peserta didik memahami catatan keperawatan pada asuhan
Keperawatan Kesehatan Jiwa

Soal 1. Baca dan diskusikan dengan teman sekelompok tentang dokumentasi catatan keperawatan.
Identifikasi satu tindakan berdasarkan kasus fiktif dan kolom implementasi dan evaluasi sesuai
tindakan yang dilakukan.

TINDAKAN KEPERAWATAN
Inisial Klien : Diagnosa Medis :
Ruang : No. Catatan Medik :

Diagnosis Keperawatan: ...............................................................................................................

IMPLEMENTASI EVALUASI
2 3
Data S:

Diagnosa O:

Tindakan

A:

P:

RTL